Recently, while seeing a long-term patient of mine for a routine visit, I looked at her chart in our electronic medical record and noticed something odd.
It seemed that suddenly she had two middle initials.
Now, I’ve taken care of her for many years and know her name, and recognize that she has a middle initial “A”, but today her name in the chart was suddenly Susan A.A. Smith (not her real name).
Since one of the requirements of our practice, to prevent medical errors, is to confirm each patient’s name and date of birth, I assumed that she had told our front desk staff that she did in fact have two middle initials and that we had mistakenly left one off through the years of taking care of her, and that this had finally been corrected. When I asked her about it during our visit she said no, she only had one middle initial, it was A, and she didn’t know how or why she suddenly had two.
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After our visit was completed, and she was headed off to the lab, I went to the front desk to inquire about this, to make sure that this problem was corrected. I did not want her going to lab and having them unable to match up her name with what we had in the system or some other electronic mismatch down the line when they tried to connect Susan A. Smith to Susan A.A. Smith.
The registrars who checked her in were not aware that this had occurred, and had no idea how it might have happened. They all said that none of them had added a second middle initial to her name, and in fact did not think they had the ability to even do such a thing.
I bumped this issue up to our practice supervisors and administrators, who finally reported back to me that it was probably a problem with the way one of our multiple systems was communicating with the others.
Our patients are registered in one system, our electronic health record is in another, and they speak to each other through an electronic bridge that passes data back and forth.
No one has been able to figure out where this glitch occurred, or how to stop it.
Strangely enough, over subsequent weeks and months, this has been happening intermittently to more and more patients. Those who have a middle initial in our system will often get a new one during the course of a visit to our practice.
Our record thus far is five.
No one seems to think it’s strange that the patient is named John M.M.M.M.M. Jones (again, not his real name) but me.
I’ve told our administrators and supervisors, as well as the support team from IT, that I worry this could lead to a problem. If one system calls you John M. Jones, another calls you John M.M. Jones, and another calls you John M.M.M. Jones, what happens when your CT scan gets resulted under John M.M.M.M.M. Jones and the system can’t find you, and no one is sure which one is really you.
A mistake waiting to happen.
As we’ve created these massive databases, electronic systems that house our data, the risk of errors getting incorporated into it has multiplied, growing exponentially.
When we try to use our databases to create systems of quality, the quality of the data going in matters.
Our care coordinators keep a large spreadsheet of the patients they are following, including their primary care providers, active medical issues, and the plan for what they’re doing to help these complex patients.
Recently, one of the care management initiatives was to set up additional meetings between the team, to focus on the highest risk patients. The spreadsheet was given to an assistant to tabulate, reshuffle so that each physician got a list of their patients that were being actively care managed.
This was then sent out to all of the physicians in the practice, with a request to set up a meeting between ourselves and the care managers in a timely fashion when our residents were available to discuss impending issues for these patients, and come up with a plan.
Unfortunately, something happened, and somewhere along the way there was a frame shift. When looking over the spreadsheet, I didn’t recognize a few of the patients on the list; some of them were not my patients, nor patients of the residents that I supervise.
I went back to the electronic health record, entered one of the medical record numbers, and discovered that these patients were followed by neither my resident nor me, but by a different resident and a different attending in a different part of the practice.
Getting bad data like this leads us to feel like it may not be worth the effort. If none of this is relevant to me, is this really going make a difference? If we got this much wrong, can any of it really be right?
Last week I got a packet in the mail, about one and a half inches thick, from one of the major insurance carriers.
Inside was a printout, nearly a dozen pages long, that turned out to be a list of patients that the insurer “attributed” to me.
The rest of the materials in the packet were long, complicated blank SOAP notes that they wanted me to fill out by hand, detailing each patient’s most recent visit with us, all recommended healthcare maintenance items, management plans, and appropriate interventions for all of their health conditions.
The first thing I noticed was that about 90% of these names were patients I’d never seen.
Ignoring the fact that there is unlikely to be much utility for me copying all of this onto a new piece of paper and then having someone else copy it over into some other database in another place, that this effort is unlikely to really help our patients.
More likely, it is just satisfying some check box created at the administrative level, so that the insurer can say that they have gone over all of these points with the primary care provider.
“MD aware”
Attribution matters. If I’ve never seen a patient, how can I be responsible for making sure that they’ve had an age-appropriate cancer screening, and that they have had an ophthalmologist visit if they have diabetes, and if they’ve received their flu vaccine this year?
These patient lists come to us from terribly outdated databases, where someone once signed up and clicked the box next to my name listing me as her PCP, but in fact has been getting her care elsewhere for years.
As we move ahead in our efforts to create a quality, safe environment for our patients, we do need effective ways to determine whether patients have had all of this stuff done. Are our diabetics getting all the interventions they need, are lipids at goal, have patients had appropriate cancer screening?
We are moving into a world where even our income will depend on quality. We need to be part of the discussion, we need to be the ones deciding what we are responsible for, and how to best document this, and how to provide this for our patients, rather than having it thrust upon us by an anonymous organization with an outdated data set.
But if you give me bad data, I assure you I will give you bad quality.
Date: September 10, 2015